Preparing For Birth: 35+ and Pregnant

Hourglass

The disturbing trend in treating ALL  “advanced maternal age”  mothers (over 35 at the time of impending birth) high risk continues to grow despite lack of evidence to do so.

My original post from 3.5 years ago still rings true today.

They are being subject to weekly Biophysical profiles or Fetal Non-stress tests tests that are normally reserved only for high-risk mothers and babies from as early as 32 weeks in pregnancy.  On top of the scans, these mothers are often pressured to agree to an early delivery of their babies by means of labor induction or cesarean even without other risk associations.  This is growing more and more prevalent especially for women over 35 who are first time mothers.

I have heard even from women that at their first OB appointment they are being told they will be induced at 39 weeks as a standard of practice and expectation for signing on with said provider.  The seed of fear and worry is being planted that their growing baby will die if the pregnancy goes to 40 weeks or longer.  What a way to start out a provider/mother relationship.  I would call that a red flag of immense proportion.

So what really is the big deal with “old” mothers?  This study Advanced Maternal Age Morbidity and Mortality correlates various medical issues with “AMA” mothers though the biggest hot button is an elevated yet unknown cause of perinatal death.  This statement alone has caused a huge shift in the way these mothers are viewed regardless of  overall pregnancy health and absence of any known risk associations. ACOG’s February 2009  Managing Stillbirths maintains there is a risk to older mothers with no explanation as to why there is a risk, what the percentage of  risk increase is or any prevention protocols.  Seems dodgy since the other groups noted in the bulletin have all the data included.

There are some serious problems with any practitioner taking this study and applying it across the board to “AMA” women.  The study even says so much, “It is important to note that the findings of this study may not be generalized to every advanced-maternal-age obstetric patient in the United States. Although the FASTER trial patient population was unselected, meaning that patients were not excluded based on any confounding factors such as race, parity, BMI, education, marital status, smoking, pre-existing medical conditions, previous adverse pregnancy outcomes, and use of assisted reproductive care, there may have been significant patient or provider self-selection.” So the population could have been skewed from the get go by provider or patient selection, along with the fact that it seems the only point of homogeneity is present in that most of the women were Caucasian.  Throw all these women in a pot and see what happens?  Next step is to make protocols and change practice style upon weak findings?

The study also shows an increased risk for cesarean by “AMA” mothers.  “As with prior literature, this study demonstrated that women aged 40 years and older are at increased risk for cesarean delivery. Older women may be at increased risk for abnormalities of the course of labor, perhaps secondary to the physiology of aging. It is possible that decreased myometrial efficiency occurs with aging. Nonetheless, maternal age alone may be a factor influencing physician decision making. It is uncertain whether the increased rates of cesarean delivery are due to a real increase in the prevalence of obstetric complications or whether there is a component of iatrogenic intervention secondary to both physician and patient attitudes toward pregnancy in this older patient population.” Very interesting. So “old” women are perceived as being unable or problematic so they have less successful vaginal birth outcomes. Now that is a self-fulfilling practice style with a huge dose of ageism thrown in.  I also wonder what the cesarean rate in this age grouping is going to be due to these protocols.

Let’s get to the perinatal and neonatal death risks.  The study says: “Studies regarding an increased risk for perinatal mortality in women of advanced maternal age have been controversial. In this study, the increased risk of perinatal mortality was not statistically significant for patients aged 35–39 years (adjOR 1.1). Age 40 years and older was associated with a statistically significant increased risk of perinatal loss (adjOR 2.2). There were only 119 stillbirths and 37 neonatal demises in total. As a result, we could not draw any meaningful conclusions about the etiology or timing of perinatal mortality in women of advancing maternal age. The reason that advanced-maternal-age patients may be at increased risk of perinatal mortality is unknown. The failure of uterine vasculature to adapt to the increased hemodynamic demands of pregnancy as women age is a proposed explanation. So in conclusion, we have no idea why this might occur and have no way of counseling “AMA” mothers to lower the risk especially those over 40. Another noteworthy thought is that this study had 79% under 34 year old women, 17% 35-39 year old women, and only 4% women over aged 40.  So with such a small grouping ALL women considered “AMA” are being put under very heavy handed protocols to delivery their babies in the 39th week of gestation.

In closing, I find it difficult to believe that anyone who reads this study would change practice style because of it and move pregnant patients who are otherwise maintaining a healthy pregnancy without risk associations to a high risk model of care. Amazingly the study itself says the same thing, “In summary, the majority of women of advanced maternal age deliver at term without maternal or perinatal adverse outcomes.” And, “The role of routine antenatal surveillance in women aged 40 years and older requires further investigation because these women seem to be at increased risk for perinatal mortality, including stillbirth. Although the likelihood of adverse outcomes increases along with maternal age, patients and obstetric care providers can be reassured that overall maternal and fetal outcomes are favorable in this patient population.”

Couldn’t have said it better myself.

Since the original posting – – – instead of women being told they must be induced in the 39th week they are now being “offered” non-medical, cesareans as a first course of action.  This sort of pressure is not evidence-based or even medically ethical in my opinion.

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2 Responses to “Preparing For Birth: 35+ and Pregnant”

  1. Toni Hill says:

    so true all about choice.

  2. It all comes down to CHOICE! OB’s and MW’s need to stop taking away a women’s CHOICE on how and where to birth her baby! Don’t make it a condition of receiving care. Let the parents know the benefits, risks and alternatives so they can make their own decision. Have them sign a paper if you want but patient autonomy needs to be honored.

    Great post, as usual, Des!